| NPI | 1831118595 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9112293) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VT 55-0030638) |
| Enumeration Date | 2006-07-19 |
| Last Update Date | 2021-03-11 |